Abstract
Purpose
Sacral insufficiency fracture (SIF) is a commonly underdiagnosed etiology of back pain, especially in the geriatric and osteoporotic population. In this clinical study, we present our experience of 185 patients who were diagnosed with SIF and managed either with conservative or surgical treatment with a minimum 5-year follow-up.
Materials and method
Patients who were diagnosed with SIF, managed either conservatively or surgically, and had a minimum 5-year follow-up medical record were included in this study. CT scans and MR imaging including coronal STIR sequence were obtained from all. Bone densitometry (DEXA) was performed to detect accompanying osteopenia or osteoporosis. Patients were treated either conservatively or surgically. VAS and ODI scores were evaluated prior to the treatment and 1st day, 10th day, 3rd month, and 1st year postoperatively.
Results
The mean age of 185 patients was 69.2 and the mean follow-up period was 7.23 years (range: 5–11 years). 46 (24.9%) patients had a previous spinal or spinopelvic surgery and spinal instrumentation was implemented in 22(11.89%) of them. The time interval between the fusion surgery and the diagnosis of SIF was approximately 9.48 weeks. The fracture line could be detected with the MRI in 164 patients and with the CT in 177 patients. The fracture was bilateral in 120 (64.8%) patients. 102 patients were treated conservatively, and 83 received sacroplasty. VAS and ODI scores showed better improvement in pain and functionality in the surgical management group than in the conservative management group.
Conclusion
SIF should be considered in the differential diagnosis of back and pelvic pain, especially in elderly and osteoporotic patients. MRI with coronal STIR imaging should be a standard protocol for patients with a risk of SIF. Our results show that sacroplasty provides better and faster pain relief and recovery than conservative management.
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References
Lourie H (1982) Spontaneous osteoporotic fracture of the sacrum. An unrecognized syndrome of the elderly. JAMA 248(6):715–717
Urits I, Orhurhu V, Callan J, Maganty NV, Pousti S, Simopoulos T, Yazdi C, Kaye RJ, Eng LK, Kaye AD, Manchikanti L, Viswanath O (2020) Sacral insufficiency fractures: a review of risk factors, clinical presentation, and management. Curr Pain Headache Rep 24(3):10. https://doi.org/10.1007/s11916-020-0848-z
Schindler OS, Watura R, Cobby M (2007) Sacral insufficiency fractures. J Orthop Surg 15(3):339–346. https://doi.org/10.1177/230949900701500320
Yoo JI, Ha YC, Ryu HJ, Chang GW, Lee YK, Yoo MJ, Koo KH (2017) Teriparatide treatment in elderly patients with sacral insufficiency fracture. J Clin Endocrinol Metab 102(2):560–565. https://doi.org/10.1210/jc.2016-3582
Sakaguchi M, Maebayashi T, Aizawa T, Ishibashi N (2019) Risk factors for sacral insufficiency fractures in cervical cancer after whole pelvic radiation therapy. Anticancer Res 39(1):361–367. https://doi.org/10.21873/anticanres.13120
Speziali A, Tei MM, Placella G, Chillemi M, Cerulli G (2015) Postpartum sacral stress fracture: an atypical case report. Case Rep Orthop 2015:704393. https://doi.org/10.1155/2015/704393
Hmida B, Boudokhane S, Migaou H, Kalai A, Jellad A, Salah ZB (2018) Postpartum sacral stress fracture associated with mechanical sacroiliac joint disease: a case report. Medicine 97(32):e11735. https://doi.org/10.1097/MD.0000000000011735
Rawlings CE 3rd, Wilkins RH, Martinez S, Wilkinson RH Jr (1988) Osteoporotic sacral fractures: a clinical study. Neurosurgery 22(1 Pt 1):72–76. https://doi.org/10.1227/00006123-198801010-00011
Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH (2012) The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat 221(6):537–567. https://doi.org/10.1111/j.1469-7580.2012.01564.x
Kinoshita H, Miyakoshi N, Kobayashi T, Abe T, Kikuchi K, Shimada Y (2019) Comparison of patients with diagnosed and suspected sacral insufficiency fractures. J Orthop Sci Off J Jpn Orthop Assoc 24(4):702–707. https://doi.org/10.1016/j.jos.2018.12.004
Su B, O’Connor JP (2013) NSAID therapy effects on healing of bone, tendon, and the enthesis. J Appl Physiol 115(6):892–899. https://doi.org/10.1152/japplphysiol.00053.2013
Lyders EM, Whitlow CT, Baker MD, Morris PP (2010) Imaging and treatment of sacral insufficiency fractures. AJNR Am J Neuroradiol 31(2):201–210. https://doi.org/10.3174/ajnr.A1666
Frey ME, Warner C, Thomas SM, Johar K, Singh H, Mohammad MS, Beall DP (2017) Sacroplasty: a ten-year analysis of prospective patients treated with percutaneous sacroplasty: literature review and technical considerations. Pain Physician 20(7):E1063–E1072
Blake SP, Connors AM (2004) Sacral insufficiency fracture. Br J Radiol 77(922):891–896. https://doi.org/10.1259/bjr/81974373
Bostel T, Nicolay NH, Welzel T, Bruckner T, Mattke M, Akbaba S, Sprave T, Debus J, Uhl M (2018) Sacral insufficiency fractures after high-dose carbon-ion based radiotherapy of sacral chordomas. Radiat Oncol 13(1):154. https://doi.org/10.1186/s13014-018-1095-x
Kawamoto T, Ito K, Furuya T, Sasai K, Karasawa K (2018) Sacral insufficiency fracture after stereotactic body radiation therapy for sacral metastasis. Clin Case Rep 6(11):2293–2294. https://doi.org/10.1002/ccr3.1850
Holderread BM, Shin CP, Syed IY, Avramis I, Rizkalla JM (2022) Sacral insufficiency fracture after lumbosacral decompression and fusion. In Bayl Univ Med Cent Proc 35(4):451–454. https://doi.org/10.1080/08998280.2022.2058832
Meredith DS, Taher F, Cammisa FP Jr, Girardi FP (2013) Incidence, diagnosis, and management of sacral fractures following multilevel spinal arthrodesis. Spine J Off J North Am Spine Soc 13(11):1464–1469. https://doi.org/10.1016/j.spinee.2013.03.025
Odate S, Shikata J, Kimura H, Soeda T (2013) Sacral fracture after instrumented lumbosacral fusion: analysis of risk factors from spinopelvic parameters. Spine 38(4):E223–E229. https://doi.org/10.1097/BRS.0b013e31827dc000
Wilde GE, Miller TT, Schneider R, Girardi FP (2011) Sacral fractures after lumbosacral fusion: a characteristic fracture pattern. AJR Am J Roentgenol 197(1):184–188. https://doi.org/10.2214/AJR.10.5902
Buell TJ, Yener U, Wang TR, Buchholz AL, Yen CP, Shaffrey ME, Shaffrey CI, Smith JS (2020) Sacral insufficiency fractures after lumbosacral arthrodesis salvage lumbopelvic fixation and a proposed management algorithm. J Neurosurg Spine. https://doi.org/10.3171/2019.12.SPINE191148
Gotis-Graham I, McGuigan L, Diamond T, Portek I, Quinn R, Sturgess A, Tulloch R (1994) Sacral insufficiency fractures in the elderly. J Bone Joint Surg Br Vol 76(6):882–886
Cabarrus MC, Ambekar A, Lu Y, Link TM (2008) MRI and CT of insufficiency fractures of the pelvis and the proximal femur. AJR Am J Roentgenol 191(4):995–1001. https://doi.org/10.2214/AJR.07.3714
Smith DK, Dix JE (2006) Percutaneous sacroplasty: long-axis injection technique. AJR Am J Roentgenol 186(5):1252–1255. https://doi.org/10.2214/AJR.05.0823
Grangier C, Garcia J, Howarth NR, May M, Rossier P (1997) Role of MRI in the diagnosis of insufficiency fractures of the sacrum and acetabular roof. Skelet Radiol 26(9):517–524. https://doi.org/10.1007/s002560050278
Finiels H, Finiels PJ, Jacquot JM, Strubel D (1997) Fractures of the sacrum caused by bone insufficiency. Meta-analysis of 508 cases. Presse Med 26(33):1568–1573
Fujii M, Abe K, Hayashi K, Kosuda S, Yano F, Watanabe S, Katagiri S, Ka WJ, Tominaga S (2005) Honda sign and variants in patients suspected of having a sacral insufficiency fracture. Clin Nucl Med 30(3):165–169. https://doi.org/10.1097/00003072-200503000-00004
Lundin B, Björkholm E, Lundell M, Jacobsson H (1990) Insufficiency fractures of the sacrum after radiotherapy for gynaecological malignancy. Acta Oncol 29(2):211–215. https://doi.org/10.3109/02841869009126547
Babayev M, Lachmann E, Nagler W (2000) The controversy surrounding sacral insufficiency fractures: to ambulate or not to ambulate? Am J Phys Med Rehabil 79(4):404–409. https://doi.org/10.1097/00002060-200007000-00014
Mahmood B, Pasternack J, Razi A, Saleh A (2019) Safety and efficacy of percutaneous sacroplasty for treatment of sacral insufficiency fractures: a systematic review. J Spine Surg 5(3):365–371
Frey ME, Depalma MJ, Cifu DX, Bhagia SM, Carne W, Daitch JS (2008) Percutaneous sacroplasty for osteoporotic sacral insufficiency fractures: a prospective, multicenter, observational pilot study. Spine J Off J North Am Spine Soc 8(2):367–373. https://doi.org/10.1016/j.spinee.2007.05.011
Pommersheim W, Huang-Hellinger F, Baker M, Morris P (2003) Sacroplasty: a treatment for sacral insufficiency fractures. AJNR Am J Neuroradiol 24(5):1003–1007
Frey ME, DePalma MJ, Cifu DX, Bhagia SM, Daitch JS (2007) Efficacy and safety of percutaneous sacroplasty for painful osteoporotic sacral insufficiency fractures: a prospective, multicenter trial. Spine 32(15):1635–1640. https://doi.org/10.1097/BRS.0b013e318074d4e1
Gupta AC, Chandra RV, Yoo AJ, Leslie-Mazwi TM, Bell DL, Mehta BP, Vanderboom TL, Rabinov JD, Larvie M, Hirsch JA (2014) Safety and effectiveness of sacroplasty: a large single-center experience. AJNR Am J Neuroradiol 35(11):2202–2206. https://doi.org/10.3174/ajnr.A4027
Park JW, Park SM, Lee HJ, Lee CK, Chang BS, Kim H (2017) Mortality following benign sacral insufficiency fracture and associated risk factors. Arch Osteoporos 12(1):100. https://doi.org/10.1007/s11657-017-0395-3
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Sarigul, B., Ogrenci, A., Yilmaz, M. et al. Sacral insufficiency fracture: a single-center experience of 185 patients with a minimum 5-year follow-up. Eur Spine J 33, 1511–1517 (2024). https://doi.org/10.1007/s00586-023-08027-2
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DOI: https://doi.org/10.1007/s00586-023-08027-2